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^^ ' „ Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Coul <br /> than 8 12 x 11 inches in size. (A r".e <br /> • See reverse side for instructions for completing this application Stateit�ry Perml�tuber <br /> The information you provide may be used by other government agency programs ❑Ch i1{//r/ev/vision to previous application <br /> ]Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number„;VA <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION (/// <br /> Propperty Owner Name operty Location <br /> l\lC_ L c. P 1/4 SC 1/4,S a& T C N, R E(OrOW <br /> Property Owner's Mailing Address y Lot Number Block Number <br /> 7S6 <br /> l'/'1 ,o )' U — <br /> Cit ,State Zip Code Phone Number Sub ivision Name or CSM Number <br /> 4"DV_1 VQyk "n. .ss"f43 ( 1�rv�foo37' hn ` QivervIel-J Feer« <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned C] City Nearest Road D <br /> Public 1 ort Famil Dwellin - No.of bedrooms a ❑ Towan OF `,JLd u w WIIr12rget Dem Rd, <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 Apartment/Condo h I a O <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line Be if applicable) <br /> A) 1. ❑ New 2_ M Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> ----------------------------------------------------------------------------------------------- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 21 []Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑ In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate . System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Mi h c1 Elevation <br /> 3b C) �a q 3 /S Feet 9,? Feet <br /> TANK Capacit <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> e or Holding Tank X 1-700 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibili y for installation of the onsite sewage system shown on the attached plans. <br /> Plum er's Name:(Prin ) Plumber's Signaturee( tamps) MP/MPRSW No.: Business Phone Number: <br /> 2 S o-e �� ;)ara a 106 o�' <br /> Plumbers Address(street,City,Sta e,Zip Code): <br /> mbJ 's <br /> O V S 66 c/P1 VV e k-P I' LJ(' <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sani ary P rmit Eey ('n`'udesGrovndwater at sue Issuing Wsegture o amps) <br /> CTV <br /> Approved ❑Owner Given Initial ZfQ/ Surcharge Fee) Q <br /> Adverse Determination <br /> CONDITIONS OF APPROVAL (REM ONS FOR DISAPPROVAL: <br /> SHD-6398(R.05/94) DISTRIBUTION: Original to Cour�l y,One n,py To: Safety 8 Buildings Dive--ion,Owner.Plumber <br />